Denial for Services Done by Staff

Q: I recently was denied for a physical medicine and rehabilitation (PM&R) service (codes 97001-97755) with the statement that the carrier does not pay when the services are not done by the doctor. In the state in which I practice, I may supervise a staff person to do physical therapy, and I have always billed under my license and been paid for the services. Therefore, is it legal for the carrier to make this denial?

A: I have had several inquiries on this issue in the past year, and it is becoming more common for carriers to inquire of the chiropractic office as to who specifically did the PM&R. It appears there is a trend toward carriers not paying for services done by unlicensed or noncertified staff. You report that your state does allow a chiropractor to supervise an unlicensed individual to provide physical medicine services. Generally, this means that so long as the chiropractor examined and set the treatment plan, support staff can perform PM&R services. The level of supervision required will vary from state to state, but typically the chiropractor must be on site, but need not be in the room in which the services are rendered. These services may and are to be billed under the treating doctor.

The crux of our dilemma is whether an insurance carrier must pay for those services and has a right to exclude payment when done by an unlicensed support staff. This is a tricky legal question that I have discussed with several health care attorneys. They all noted that it is certainly within the scope of practice to supervise and have the staff do the service, but is not necessarily protected against a payer requiring only licensed or certified individuals.

They reported no laws that require a payer to pay for services done by unlicensed staff, similar to Medicare not allowing payment for "incident to" services when not done by licensed or certified individuals. Legally, this policy is not preventing chiropractors from practicing within their scope, but it means they will not be paid for services done by noncertified staff.

I have further researched and discussed this with several payers, and they stated that the chiropractor may indeed have an unlicensed person do the service. The majority of payers noted they make no distinction about payment as long as the care is performed, documented and supervised. But a few did indicate they do not reimburse for services by nonlicensed or noncertified staff. I asked about the deference to the state law and they stated unequivocally that their reimbursement rules are not based on an individual state law. They also stated that their reimbursement rules were to ensure the highest quality and safety of the services provided, and that noncertified staff does not allow for any consistency from office to office that the services were done correctly or safely. They did note they would pay for services done by staff who had state certification as a "chiropractic assistant." They also stated that they do not pay for PM&R in a physical therapist's office if the person is not a certified PT assistant.

I found that only 10 states have such certification. So if this trend continues, we as a chiropractic profession are going to have to battle this legally and force payment per state regulations or implement certification of chiropractic assistants. In conclusion, the direct answer to your question is yes, they can deny payment, but you may have a legal challenge if you wish to pursue it.